Inspection on 21/06/06 for Drayton Wood

This inspection was carried out on 21st June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Drayton Wood 08/06/09

Drayton Wood 09/06/08

Drayton Wood 14/06/07

Drayton Wood 04/01/06

Drayton Wood 26/07/05

Drayton Wood 18/01/05

Drayton Wood 24/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Drayton Wood Drayton High Road Drayton Norwich Norfolk NR8 6BL Lead Inspector Mrs Judith Huggins Unannounced Inspection 21st June 2006 02:30 Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Drayton Wood Address Drayton High Road Drayton Norwich Norfolk NR8 6BL 01603 409451 01603 426568 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Benell Care Services Limited Ms Sonja Serruys Care Home 29 Category(ies) of Learning disability (29) registration, with number of places Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. In total twenty-nine (29) people of either sex, who have a learning disability, may be accommodated. Nine (9) people, of either sex, with a learning disability may be accommodated in Drayton Wood main house. Six (6) people, of either sex, with a learning disability may be accommodated in Cedar Lodge. Seven (7) people, of either sex, with a learning disability may be accommodated in Holly Lodge. Seven (7) people, of either sex, with a learning disability may be accommodated in Honeysuckle Lodge. The age gap between the youngest and the oldest person accommodated in Honeysuckle Lodge will be no more than 25 years. 4th January 2006 Date of last inspection Brief Description of the Service: The home is registered to provide services to adults with learning disabilities who are between the ages of 18 and 65 years. Drayton Wood is set in seven acres of landscaped gardens and forty acres of woodland. In the grounds there are pens for pygmy goats and chickens and there is an aviary. At the present time there are on the site four houses accommodating service users. Drayton Wood is the main building. This was constructed in 1900. There are three much more recent purpose-built houses, known as Holly Lodge, Cedar Lodge and Honeysuckle Lodge. Although the four units are registered as one, they function almost independently of each other, with separate staff teams and service users with different needs. The main house, Drayton Wood, provides accommodation for up to nine service users. There is one shared bedroom and seven single bedrooms. Seven of the eight rooms have en-suite facilities. There is a large lounge and dining area and a dedicated, and a very busily colourful, day care centre. Cedar and Holly Lodges each provide accommodation for six and seven service users respectively, in single bedrooms with en-suite facilities. Honeysuckle Lodge was registered in January 2006 to accommodate 7 people and at the time of the inspection, there were 3 people living there. When fully operational it will provide accommodation for up to 7 younger adults with an age range not exceeding 25 years between the youngest and oldest persons. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 5 One further unit for 7 people, Spruce Lodge, remains yet to be completed. The home is located within easy access to the City of Norwich and other nearby towns and villages. Drayton Wood was awarded the Investors in People Award in December 2004. Fees are from £441 to £871 per week, dependent upon needs and dependency, with additional charges for hairdressing, chiropody, transport and personal spending. The manager says that the inspection report is made available to people who ask for it, but not left accessible as it would be destroyed. One out of three relatives (one third) responding in written comment cards did not know how to access the report and the manager acknowledges that access can be improved. Following issue of the draft report the manager has written to all relatives to tell them how they can access the report. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. Two visits were made to the home. No one knew the inspector was going on the first visit. The second one was arranged to get more information and see the person who organises training. These visits lasted about five and a half hours in total. The inspector got information from care plans and other records, from the manager, deputy and five members of staff including the training person. Sixteen residents, three relatives and one other visit sent written comments. Six residents talked to the inspector, and three others showed their rooms to her. The inspector also listened to staff talking to and working with the people living at the home. Some of the things people wrote down or told her, have been included in this report. Some parts of the houses and gardens were seen. Overall, the service is considered to be adequate now but it is moving in the right direction to improve this. What the service does well: The staff were heard talking to residents and explaining some things simply and clearly. Some of them have worked at the home for a long time, and know the people they are supporting, very well. Over half of the staff have done training to get qualifications that help them to care for people living at the home. Residents say that they like living at the home, and that the staff look after them well. Some say they get on very well with their keyworkers and that they have friends in the other houses. The place the homes are built in means that residents can have peace and quiet outside if they want to, but can also get to the town, shops, pubs etc, with help. The home has cars to use to help with this. People living there generally have good lifestyles. All of the residents know that they have a care plan, and some of them sign some of the things that are put into it. Records are made on computers that are linked between the houses. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have information about the home, their needs are assessed and they have the opportunity to “test drive” the home. EVIDENCE: Information about what the home can offer to residents has been drawn up in pictures that can be discussed with prospective service users, and also in “widget” symbols. The statement of purpose has been revised so that it clearly sets out the facilities offered within the different houses. Both requirements made under standard 1 at the last inspection are considered met. The file for one person newly admitted to the home was checked. This has a good range of information about the person’s history and needs, as well as medical conditions, and there is reference material for staff to refer to regarding these. The person themselves confirmed that they had visited the home before coming to stay and talked about what they wanted to do. There are forms in use for collecting a range of relevant information, and assessments and specific care plans (such as a nutritional care plan) have been obtained from other professionals. The restrictions necessary in the person’s best interests and arising from the input from other professionals are documented within the file. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 10 The admissions process for another person was discussed with two members of staff and the manager. This shows that compatibility with other residents is taken into account and that people are given the chance to come for tea visits and overnight stays. Contracts seen show that there is a trial period, and records show that this is reviewed. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know their needs and the things they would like to do are reflected in their individual plans. They are supported to make decisions and to take reasonable risks. EVIDENCE: The inspector checked files for three people. These set out each person’s needs in a range of areas, and describe any limitations that might be necessary in the person’s best interests. Records show that reviews take place and that family members attend these where available, as do other professionals involved in the person’s care. Records give an outline of risks in a range of areas, although these were not explored in detail. Each person spoken to clearly identified his or her keyworker, two speaking very highly of the support offered. One person says that their keyworker is good at helping them to calm down when they get cross. All say that they discuss their care (one said “sometimes”). All of the comment cards received Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 12 show that residents are aware they have care plans. Records seen show that residents are encouraged to sign their records. On the day of the first fieldwork visit to the home, a group of residents had attended a session run by the local authority and designed to help people to speak up for themselves. This is good practice. There is evidence on file that residents are helped to manage their finances where required. One person spoken to confirms that they manage small amounts of money for themselves. During the inspection, residents requested money from staff on duty for their planned outings during the evening. A note on file from the manager to a staff member showed that a resident had “chosen” them as keyworker. The manager confirms that keyworkers are allocated after residents and staff get the chance to know each other. One resident confirms that they chose the keyworker who supports them. A requirement made regarding risk assessments, by the previous inspector in the last but one inspection was not repeated and when the standard was reinspected at the last fieldwork visit, was considered met. Nothing was noted as this visit to show that there was any deterioration in outcomes for this area. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to engage in appropriate activities, inside and outside the home, and are supported with relationships. Their rights and responsibilities are recognised. They are also offered a healthy diet and enjoy their meals. EVIDENCE: The Commission’s records show that the home has consistently met the key standards for achieving good lifestyles for residents. One staff member has attended comprehensive training in developing communication skills, and in discussion had a good understanding of different types of communication, including that challenging behaviour could sometimes result from difficulties with communication. He is working towards developing communication strategies with the person concerned and developing a Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 14 reference resource for other staff involved in the person’s care. The training coordinator says that there are other staff currently undergoing this training and that there will be one person in each house and one in the day care service who have this and can support other staff in communicating with residents (and vice versa). This is a welcome development and good practice. Records continue to show a good range of activities for residents, confirmed in discussion. On the evening of the inspection, groups of residents were planning attendance at the Wednesday club, and another group was going out with staff to a local public house. The home’s own vehicles and a taxi were used. The management team have addressed concerns expressed by relatives about the need for improvement in activities at Cedar Lodge by moving staff round, and anticipate an improvement the next time this area of service quality is checked. One resident discussed some difficulties with personal relationships, and others made reference to friends or relatives who are important to them. Care plans make reference to sexuality, and also to family contact and the arrangements for this. Residents confirm that they visit family (or that family and friends visit them). During the course of the fieldwork visit, staff were seen to knock on people’s doors before entering their rooms. All residents completing comment cards say that they can keep things that are theirs private. One person in one of the small units had a doorbell fitted but this was not working. A recommendation has been made. Residents who are able to manage keys are given these, one producing it, and one saying that they had one but were not sure where it was. Seven out of sixteen completing comment cards say they have keys. Notes show one person being encouraged to lock their door if they wished to do so, in order to prevent unwanted intrusions from another (to whom the importance of privacy was explained). All residents spoken to confirm that they have time in the home to do their personal chores, including tidying their rooms and doing laundry. The manager says that she has approached purchasers about annual holidays for existing residents but has had limited response. She has included this in contracts for residents recently placed. One person spoken to confirmed making holiday plans for September. Throughout the inspection, staff communicated well, clearly and calmly with residents, explaining options open to them and answering questions. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 15 Residents confirm that food is good. Preferences for one person are recorded and where red meat is on the menu, alternatives preferred by the resident are offered. Residents have pleasant environments for eating their meals in all houses, although in one the dining room was uncomfortably hot as the boiler is located here and is set to provide hot water. Nutritional care plans involving the dietician are in place where needed, and there are records showing that day services are involved in trying to ensure these are followed. There is reference material for staff as well as guidance for recording blood sugar, restrictions imposed, and records show weight is monitored. As required at the last inspection, rules regarding the consumption of drugs, alcohol and smoking have been included in the contracts seen. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive support in the way they require and their health needs are met. Medication is managed appropriately. EVIDENCE: The manager says in response to the last report, that residents prefer chiropody treatment to take place in main lounge areas. Residents did not express a preference to the inspector and otherwise say their privacy is respected. Residents do say that they are able to keep things private. The requirement is not repeated although a recommendation for good practice has been made. A visiting health professional confirms that they are able to see their client in private and that their advice is incorporated into the residents’ care plans. The pre inspection questionnaire shows a range of health care professionals provide input, and this is confirmed by information held within residents’ files. Fifteen of the sixteen residents completing comment cards say that they feel well cared for, one feels well cared for sometimes. All of the comment cards say Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 17 that staff treat them well. All confirm that they see dentists or doctors from time to time. One staff member was observed during the process of administering medication. This was given to residents one at a time, from the original packaging and with reference to the medication administration records detailing dosages. (Records themselves were not checked.) Two staff members confirm that they have had some training in the use of the system from Boots pharmacy and say they believe more training is planned. The training coordinator confirms information about other training and an alternative source of appropriate training was discussed. Care records contain information about residents’ medication and what it may be for. The staff members confirm that they access the information when necessary, for example when considering whether periodic “when necessary” medication should be given. They say they are also able to obtain advice from the manager or the deputy should this be needed. Care records show that a mistake in administration had been made and that this was due to a pharmacy error in package labelling. The deputy manager confirms this. This was detected, reported, and the appropriate emergency advice was sought based on records. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives can be confident their concerns will be taken seriously and they are protected from abuse. EVIDENCE: Residents comment cards say that they all know who to speak to if they have concerns about their care. Three residents who were asked, say that they would speak to staff but do not have any concerns at present. There is a simplified version of the complaints procedure available for residents, in “widget” symbols. Complaints are recorded and acted on, based on records. One of the three relatives responding on comment cards did not know what the complaints procedure was although previous inspections show that relatives are given this information. Residents expressed some concern in comment cards, that they would like there to be less arguments. The manager says that these predominantly related to past events now resolved. Residents say that things are better now. The ability of the service to meet needs is kept under review based on discussions with the manager about placement, and on a health professional’s comment card. This says the person considers that the manager takes appropriate decisions when the home can no longer meet needs. Training certificates show that staff have received training in abuse awareness for vulnerable adults. The training coordinator confirms that she has Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 19 undertaken training to allow her to deliver this. Training records also show that staff have received training in managing aggression. Fifteen out of sixteen residents in comment cards say that they feel safe at the home, and one feels safe sometimes. This could not be followed up at inspection as no name was given on the comment card. Residents spoken to were happy with the service they had. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Redecoration, repair and refurbishment are needed in a range of areas to ensure outcomes are met, although generally accommodation is good quality. EVIDENCE: The heating system in the main house has been replaced since the last inspection. Radiators are now fitted with controls so that residents can adjust them in their own rooms. The manager says that no residents are considered to be at high risk from hot surfaces but that radiator covers are on order. The requirement made at the last inspection remains partially outstanding in this regard. Because of the work undertaken there is a significant amount of redecoration required. There are also additional matters needing attention. The manager needs to submit a schedule showing how and by when, each of the following matters will be addressed. A requirement has been made. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 21 • • A carpet on the first floor of the main home is also in need of relaying or replacement as this is wrinkled and taped at two locations. There are two places where the roof has leaked (in the fridge room and by the laundry. The manager says that the landlord needs to repair the roof so that the internal damage can be repaired. The cold water tap by the laundry entrance and side door cannot be turned off properly and is dribbling. There are tiles missing from the wall in the kitchen that need replacement There is a pile of broken furniture on the grass by the approach road that needs disposal. The sofa in the reception hall of the main home is damaged (holed and with stuffing having been picked from it). • • • • The newer units are generally well maintained, based on areas seen. In all units residents benefit from rooms that are personalised to reflect their interests, and communal areas with good quality domestic type furnishings. The requirement made at the last visit, that security lighting be fitted between the houses, has been met. This is not functioning correctly in that it is permanently on, but does mean that pathways are appropriately lit at night. Residents have access to extensive grounds that are, for the most part, well maintained. As the work to the heating system in the main home has only recently been finished, the laundry has not yet been refurbished to fully meet the appropriate standard. Work is needed to the kitchen area and therefore, as at the last inspection, the standard about cleanliness and hygiene cannot be seen as fully met. The requirement is repeated. However, other areas within the main and small homes seen are generally clean and odour free. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. However, were recruitment checks to be improved and made in a timely manner, and the frequency of supervision improved, the outcome would be good. Residents are not wholly protected by recruitment procedures at present, and although supported, not all staff are supervised adequately. Residents’ needs are met by appropriately trained staff. EVIDENCE: There is a staff member specifically dedicated to sourcing and delivering training. She is aware of the forthcoming changes in induction standards. Staff members hold their own induction records and so these were not seen. The Learning Disability Awards Framework (LDAF) is not used to deliver induction. However, staff were seen as working well with residents. There are, based on the training matrix and discussion with the training manager, 9 staff with NVQ level 2 qualifications or above. This is higher than the figure given in the pre-inspection questionnaire and shows a good commitment to enabling staff to achieve the qualification. A sample of certificates was seen. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 23 The staffing records show that some people have commenced their employment without the appropriate checks against the list for the protection of vulnerable adults, and contrary to Commission and department of health guidance. The manager was unclear about the Pova First facility and extracts from the above guidance was provided for the manager at the second fieldwork visit. Recruitment checks have been the subject of requirements at the last two inspections and remain inadequate. The requirement is repeated and must now be met to avoid enforcement action. The manager says that she sees the staff on duty each time she is on the premises and the deputy manager confirms that she is able to raise matters as they arise. Supervision of staff in the smaller units is delegated to the senior staff in charge on those units, with the manager supervising them and the staff in the main home. However, records do not show that this is delivered to all staff with the frequency and agenda set out in the minimum standards. For example, one person’s notes show formal supervision sessions recorded for three occasions in 2003, one in 2005, and one in February this year. A requirement has been made. There are staff meetings, based on records seen. These vary in frequency. The manager and deputy confirm that appraisals are now due. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is appropriately managed. There are minor shortfalls in the promotion of health and safety. Good progress has been made in ensuring that service users views (and those of their relatives) about the quality of the service are taken into account with some further work needed. EVIDENCE: The manager is, based on discussions, well aware of her responsibilities and is supported by a deputy manager. Both have a good understanding of the needs of the service and residents in their care. The manager attends a “providers’ forum” to keep up to date with issues in the area. The standard was last inspected in 2003, and deemed met. The manager is the same as was in post at that point. Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 25 The manager has completed analysis of a survey of relatives carried out last year, and taken action to address the shortfalls identified. She says that this survey is now being repeated. She has yet to complete the analysis of the survey of residents’ views about the quality of the service although these have been sought. The requirement made at the last inspection has not therefore been repeated. Residents say in comment cards that they have meetings to talk about what’s good and what could be changed. There are some notes from these meetings. However, records do not show that suggestions are considered, taken up or checked at subsequent meetings whether residents are happy with the outcome. A recommendation has been made. There is a need to improve the frequency nature and content of reports from visits made on behalf of the registered provider. Monthly visits are needed throughout the service. There was no evidence available that the wiring of the main home had been checked recently and certified as safe, but the deputy manager says this has been done, as there was a lot of work needed as a result. A requirement has been made. There are records of regular testing of alarm points based on the information seen in the main home. The deputy manager confirms that one fault identified to an emergency light had been rectified and says that all of the requirements of the fire officer’s inspection in September 2005 have been acted upon. The annual testing of fire extinguishers in one of the smaller units is overdue (needed in May). The deputy manager checked this and arranged with the contractors for this to be carried out during the second fieldwork visit. The majority of staff have undertaken training in health and safety, emergency first aid, food safety and moving and handling with updates planned by the training coordinator (based on the training matrix supplied). Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 1 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 2 x Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 13.4.a & c Requirement Partially outstanding requirement The Registered Persons must ensure that arrangements are made for residents to be protected from hot radiator surfaces. Following issue of the draft report the manager confirms these are ordered and the manufacturer’s are attempting to fulfil the timescale applied. The registered persons must submit a schedule incorporating priorities and given a reasonable rationale for timescales, to ensure that identified refurbishment work is attended to. This was received following publication of the draft report and within timescale. Outstanding requirement The Registered Persons must ensure that the laundry is refurbished to meet National Minimum Standards. Following issue of the draft report the manager confirms the area has been refurbished DS0000027499.V301432.R01.S.doc Timescale for action 31/08/06 2. YA24 23.2.b & c 31/07/06 .3. YA30 16.2.j) 30/09/06 Drayton Wood Version 5.2 Page 28 within timescale applied. 4. YA34 19.b.i Outstanding requirement The Registered Persons must ensure that the homes recruitment procedures fulfil all the requirements set out in Regulation 19 and Schedule 2 as amended, of the Care Homes Regulations 2001. Following issue of the draft report, the manager confirms remedial action has been taken within timescale applied. The registered persons must ensure all staff are supervised with the agenda and frequency set out in National Minimum Standards. The registered persons must ensure visits on behalf of the registered provider are carried out with the frequency, nature and content set out in regulations. The registered persons must provide evidence that the wiring for the main home on the site has been tested and certified as safe. This evidence was supplied by the due date following issue of the draft report. The registered persons must provide evidence that the fire extinguishers overdue for testing, have been appropriately tested. This evidence was supplied by the due date and following the issue of the draft report. 31/07/06 5. YA36 18.2 31/08/06 6. YA39 26 31/07/06 7. YA42 13.4 & 23.2.b & c 30/06/06 8. YA42 23.4.c.iv 30/06/06 Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA16 YA17 Good Practice Recommendations The registered persons should repair the doorbell to one person’s room that was not functioning. The registered persons should review the timing for the boiler generating hot water and located in a dining room, to ensure that this room remains as comfortable as possible for residents to eat their meals in during the summer months. The registered persons should consider use of residents’ own rooms, or screening in order to deliver foot care with some degree of privacy. The registered persons should ensure that suggestions made and views expressed during residents’ meetings are considered, acted upon and addressed. Having canvassed their views once beforehand, the Registered Persons should follow up enquiries with partner agencies and other professionals, such as Community Nurses, GPs, social workers, off site day care staff etc for their perceptions of how the service is being delivered. This is a useful quality assurance tool. Regulation 24(3) refers. 3. 4. 5. YA18 YA39 YA39 Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Drayton Wood DS0000027499.V301432.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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